BioMed Central
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Child and Adolescent Psychiatry and
Mental Health
Open Access
Research
A three-country comparison of psychotropic medication
prevalence in youth
Julie M Zito*
1,2
, Daniel J Safer
3
, Lolkje TW de Jong-van den Berg
4
,
Katrin Janhsen
5
, Joerg M Fegert
6
, James F Gardner
1
, Gerd Glaeske
5
and
Satish C Valluri
1
Address:
1
Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA,
2

Prescription hypnotics were half as common as anxiolytics in Dutch and US youth and were very uncommon in
German youth. Concomitant drug use applied to 19.2% of US youth which was more than double the Dutch use
and three times that of German youth.
Conclusion: Prominent differences in psychotropic medication treatment patterns exist between youth in the
US and Western Europe and within Western Europe. Differences in policies regarding direct to consumer drug
advertising, government regulatory restrictions, reimbursement policies, diagnostic classification systems, and
cultural beliefs regarding the role of medication for emotional and behavioral treatment are likely to account for
these differences.
Published: 25 September 2008
Child and Adolescent Psychiatry and Mental Health 2008, 2:26 doi:10.1186/1753-2000-2-26
Received: 17 April 2008
Accepted: 25 September 2008
This article is available from: />© 2008 Zito et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( />),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Child and Adolescent Psychiatry and Mental Health 2008, 2:26 />Page 2 of 8
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Background
Increased psychotropic medication prevalence for youth
has been reported during the last decade in the UK, Ger-
many, Italy, Denmark, and the Netherlands, as well as in
the US. Drug subclasses that have increased the most have
been the selective serotonin reuptake inhibitor (SSRI)
antidepressants and the atypical antipsychotics [1-4].
There are, nonetheless, major cross-national differences in
psychotropic prevalence by drug class and subclass, gen-
der and age group [5].
The variability in US-European psychotropic medication
practice patterns reflects many differences such as diag-
nostic systems, practice guidelines, drug regulations,

year 2000. Claims records were organized with patient as
the unit of analysis and duplicate records were removed.
The treatment data were restricted to youth in outpatient
settings.
Data sources
Netherlands data
were derived from pharmacy dispensing files from the
Inter-Action database (IADB.nl). The IADB comprises all
prescriptions from approximately 400,000 people in
north-eastern Netherlands. This database includes all pre-
scriptions regardless of prescribing specialty, insurance, or
reimbursement status, apart from OTC drugs. Youth aged
0 through 19 numbered 110,944 during 2000.
German data
were derived from individual level prescription data from
the Gmuender ErsatzKasse (GEK), one of about 270 dif-
ferent statutory health insurance companies in Germany.
Nearly 90% of the 82 million German inhabitants are
members of a statutory health insurance company.
Although many such companies are quite small and rep-
resent only regional participation, the GEK comprises 1.6
million members located in all regions of Germany. The
data from the GEK are representative of the 72 million
Germans who are enrolled in a statutory health insurance
company (SHIC). The data file for this analysis comprised
356,520 enrollees who were less than 20 years old in
2000.
United States data
were derived from administrative claims files from a nar-
rowly defined population of youth whose family income

not have diagnoses available on indications for their use.
Child and Adolescent Psychiatry and Mental Health 2008, 2:26 />Page 3 of 8
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Consequently, to improve the validity of anticonvulsants
for mood stabilizer use, we restricted the analysis to ATC-
MS users who additionally had one or more psychotropic
classes in the study year, thereby excluding those most
likely to receive these medications for the treatment of sei-
zure disorder. Concomitant drug use refers to combina-
tions of medications used concurrently and the analysis
compared monthly combination drug dispensing within
3 time frames: 1 year, 3 months and 1 month, to assess the
effect of each time frame on the prevalence of co-prescrip-
tion. As in the prevalence of any psychotropic medication
use, concomitant use with ATC-MS data was adjusted by
excluding individuals who had ATC-MS dispensed but no
other psychotropic medications during the study year.
Analysis
The cross-sectional analysis describes the total, age-and
gender-specific prevalence across three countries. The age
and gender distributions of the enrolled youth (denomi-
nator) were adjusted applying the direct standardization
method and using the 2000 US census population esti-
mates as the standard population [16]. This adjustment
corrects for the imbalanced age distribution caused by the
US data with its higher proportion of 0–4 year olds and
permits fair comparison across countries. Annual preva-
lence and the 95% confidence intervals (Cls) estimated by
the exact method [17] are presented. Confidence intervals
at the 95% level for these standardized total estimates

lands and US rates were equivalent (0.9%).
Table 3 illustrates that there was a limited but disparate
use of lithium (< .01% in German, 0.01% in Dutch and
0.15% in US youth) and antiparkinsonian agents (0.01%
in German and Dutch and 0.05% in US youth). Anxiolytic
use was greater in Dutch youth than in German and US
youth, respectively: 0.73% compared to 0.41% and
0.49%. Hypnotic use was twice as common in Dutch
youth compared with US but scarcely used in German
youth (0.09%). There was a wide disparity across coun-
tries in alpha-agonist use which was 9-fold and 120-fold
more common in US youth than in Dutch and German
youth, respectively.
Antipsychotic prevalence in the countries assessed for year
2000 is presented on Table 4. In rank order, the preva-
lence of antipsychotics was 0.76% (US), 0.51% (Nether-
lands), and 0.34% (Germany). Though the total
antipsychotic cross-national prevalence differences were
relatively modest, Germany's prevalence was strikingly
different in three respects. Atypical antipsychotics repre-
sented only 5% of the total in Germany, but 48% in the
Netherlands and 66% in the US. The antipsychotic gender
ratio (M:F) was distinctly lower in Germany (1.4:1) com-
pared to the Netherlands (3.2:1) and the US (2.8:1). Fur-
Table 1: Age and gender characteristics for enrolled youth in 3 countries during 2000
US Netherlands Germany
Age (yr) Male Female Total Male Female Total Male Female Total
0–4 33,419 32,316 65,735 14,069 13,295 27,364 38,473 36,774 75,247
5–9 13,016 12,492 25,508 13,296 12,806 26,102 45,236 43,055 88,291
10–14 9,828 9,601 19,429 13,246 13,140 26,386 52,185 49,710 101,895

were prescribed the TCA antidepressant subclass, whereas
the proportion for TCAs was 48% in the Netherlands and
73% in Germany.
Table 2: Prevalence per 100 and 95% CIs for the use of any psychotropic drug during the year 2000
US (n = 127,157) Netherlands (n = 110,944) Germany (n = 356,520)
Age(yr) Male Female Total* Male Female Total* Male Female Total*
0–4 1.21 0.52 0.88 1.00 0.71 0.86 1.86 1.38 1.63
1.10–1.34 0.45–0.61 0.87–0.88 0.84–1.18 0.58–0.87 0.85–0.87 1.73–2.00 1.26–1.51 1.62–1.63
5–9 11.95 4.38 8.25 3.99 1.30 2.68 2.85 1.19 2.04
11.39–12.52 4.03–4.75 8.25–8.26 3.66–4.33 1.11–1.52 2.67–2.69 2.69–3.00 1.09–1.30 2.04–2.04
10–14 14.16 5.97 10.17 5.38 1.95 3.71 3.37 1.33 2.38
13.48–14.87 5.5–6.46 10.16–10.18 5.00–5.78 1.72–2.2 3.70–3.72 3.22–3.53 1.23–1.44 2.37–2.38
15–19 7.62 6.30 6.98 4.35 4.44 4.40 1.75 2.12 1.93
7.01–8.26 5.82–6.82 6.97–6.99 4.04–4.68 4.12–4.78 4.39–4.40 1.63–1.87 1.99–2.26 1.93–1.93
Total* 8.87 4.35 6.66 3.72 2.11 2.94 2.47 1.50 2.00
8.86–8.87 4.34–4.35 6.66–6.67 3.72–3.73 2.11–2.12 2.94–2.94 2.47–2.47 1.5–1.51 2.00–2.00
*Totals were adjusted to the child and adolescent population of the US 2000 census by the direct standardization method.
Table 3: Prevalence per 100 and 95% CIs for the use of six* selected psychotropic drugs during the year 2000
US (n = 127,157) Netherlands (n = 110,944) Germany (n = 356,520)
Male Female Total* Male Female Total* Male Female Total*
Alpha-Agonist 0.74 0.18 0.47 0.07 0.02 0.05 0 0 0
0.62–0.86 0.14–0.22 0.43–0.51 0.05–0.1 0.01–0.03 0.03–0.07 0–0.01 0–0.3 0–0.03
Lithium 0.18 0.13 0.15 0 0.01 0.01 0 0 0
0.08–0.25 0.06–0.21 0.07–0.23 0–0.02 0–0.02 0–0.02 0–0 0–0.01 0–0.1
Anxiolytic 0.51 0.47 0.49 0.65 0.81 0.73 0.4 0.42 0.41
0.46–0.58 0.41–0.54 0.42–0.55 0.6–0.74 0.74–0.92 0.68–0.81 0.36–0.44 0.38–0.46 0.38–0.44
Hypnotic 0.15 0.17 0.16 0.35 0.32 0.33 0.08 0.11 0.09
0.12–0.2 0.14–0.21 0.14–0.21 0.31–0.41 0.27–0.4 0.3–0.39 0.07–0.09 0.1–0.14 0.07–0.13
Antiparkinsonian 0.07 0.04 0.05 0.01 0.01 0.01 0.01 0.01 0.01
0.03–0.09 0.01–0.07 0.02–0.07 0–0.02 0–0.02 0.01–0.02 0.01–0.02 0–0.02 0.0–0.02

use was entirely pairs except for one triplet. Since the bulk
(62%) of the German combinations involved anticonvul-
sant-mood stabilizer and an anxiolytic/hypnotic, it is not
possible to determine the extent of seizure disorder treat-
ment. The other German pairs were ranked as follows:
stimulant and antipsychotic (8.9%), anticonvulsant-
mood stabilizer and antipsychotic (7.6%) and stimulant
and anticonvulsant-mood stabilizer (6.3%). Concomi-
tant use with anticonvulsant-mood stabilizers affected
5.8% (110/1908) of US medicated youth, 1.9% (18/937)
of medicated Dutch youth and 4.6% (62/1358) of medi-
cated German youth.
Discussion
The major finding of this cross-national prevalence study
of psychotropic medications prescribed for youth is that
the US prevalence exceeds Western European prevalence
Table 4: Prevalence per 100 and 95% CIs for the use of antipsychotics during the year 2000
US (n = 127,157) Netherlands (n = 110,944) Germany (n = 356,520)
Age (yr) Male Female Total* Male Female Total* Male Female Total*
0–4 0.11 0.02 0.07 0.14 0.05 0.10 0.74 0.53 0.64
0.08–0.15 0.09–0.45 0.06–0.07 0.09–0.22 0.02–0.11 0.09–0.10 0.65–0.83 0.45–0.60 0.63–0.64
5–9 1.04 0.20 0.63 0.76 0.16 0.47 0.29 0.16 0.23
0.87–1.23 0.13–0.30 0.62–0.64 0.62–0.92 0.10–0.24 0.46–0.47 0.24–0.34 0.12–0.20 0.22–0.23
10–14 1.57 0.56 1.08 1.26 0.29 0.79 0.27 0.14 0.21
1.33–1.83 0.42–0.73 1.07–1.09 1.08–1.47 0.21–0.4 0.78–0.79 0.22–0.31 0.11–0.18 0.20–0.21
15–19 1.60 0.80 1.21 0.85 0.45 0.66 0.30 0.32 0.31
1.32–1.92 0.63–1.00 1.20–1.22 0.71–1.00 0.35–0.57 0.65–0.66 0.26–0.36 0.27–0.38 0.31–0.31
Total* 1.10 0.40 0.76 0.76 0.24 0.51 0.39 0.28 0.34
1.09–1.10 0.40–0.40 0.75–0.76 0.76–0.77 0.24–0.24 0.51–0.51 0.39–0.40 0.28–0.28 0.34–0.34
*Totals were adjusted to the child and adolescent population of the US 2000 census by the direct standardization method.